This is where I’ll invoke the articles on the PrePex as an example. My objection to the recent pieces about it centers on the poor journalism rather than the device. I expect the device will eventually be tweaked to allow for infant circumcision at some point. That would be wrong. For now it’s a device for voluntary, adult circumcision. I have no objection to that. The claimed risks involved with the device are low. The claim that adult circumcision is more dangerous than infant circumcision doesn’t appear to hold up, generally, regardless of the method. This claim is a framing device of dubious quality rather than a fact to be [sic] negate ethics.

I expect the device will eventually be tweaked to allow for infant circumcision at some point. And four years later, this press release, from last month (emphasis in original, footnote added):

The World Health Organization (WHO) expanded the Intended Use of the currently-prequalified PrePex device to include adolescents aged 13 years, and above. Effective immediately, the PrePex device, manufactured by Circ MedTech, can be offered for adult and adolescent males in the 14 priority countries in Southern and Eastern Africa. PrePex was the first male circumcision device to receive WHO Prequalification on 31 May 2013.

Circ MedTech’s CEO, Eddy Horowitz said: “The expanded use of PrePex for younger ages will sustain Voluntary [sic] Medical Male Circumcision (VMMC) programs in the 14 Sub-Saharan Africa priority countries and will serve the new UNAIDS Sustainable Development Goal (SDG) of an additional 27 Million male circumcisions by the year 2020.”

Circ MedTech Ltd. is in the advanced stages of adapting its PrePex technology for use with infants¹ and children, thus offering safe male circumcision services to all ages, worldwide.

At least they dropped their lie about “voluntary” in the last paragraph. But they still include it in their FAQs.

Why is it called “Voluntary Medical Male Circumcision?”

“Voluntary Medical Male Circumcision” is a term used by the global health community to emphasize that circumcision is a personal choice.

“Voluntary Medical Male Circumcision” is a term used by the global health community for propaganda. The global health community (i.e. public health officials) does not care, has not cared, and apparently will not care, about “voluntary” (or even “medical”, since this surgery is “medicalized”, not medical, circumcision). The expansion of PrePex to children who can’t consent demonstrates this. Volunteer and volunteered are not synonyms here. The global health community legitimizes whoever’s choice results in a statistic, the removal of another normal, intact male’s foreskin. Remember, the measure of success in these campaigns is “male circumcisions”, not something relating² to HIV infection rates, the alleged, stated aim of “Voluntary” “Medical” Male Circumcision.

If those involved with PrePex cared about ethics, this expansion of the product line wouldn’t occur. But here we are with the above evidence and the questions raised by more from their FAQs, such as:

What is Voluntary Medical Male Circumcision? (click to read answer)

In 2007, the World Health Organization (WHO) and UNAIDS announced recommendations,based on extensive studies, to scale up Voluntary Medical Male Circumcision (VMMC) to men in areas of high risk for heterosexual HIV transmission. The studies showed that men with a circumcised penis are approximately 70 percent less likely to contract HIV from heterosexual intercourse than men with an uncircumcised penis–in addition to other health and hygiene benefits.

This finding, replicated in rigorous, repeated studies across several countries, has led doctors and public health professionals to recommend that men in high-risk areas have access to VMMC.

Imagine a person who doesn’t know what Voluntary Medical Male Circumcision is. Now imagine that person reading the answer PrePex gave to his question, “What is Voluntary Medical Male Circumcision?”. Does he now know what Voluntary Medical Male Circumcision is? Circ MedTech already showed they don’t know what “voluntary” or “medical” mean. They should be able to pretend better than the word salad they provide.

Let me try:

What is Voluntary Medical Male Circumcision?

Male circumcision is the permanent removal of the foreskin (i.e. male prepuce), the fold of skin covering the penis. This may also involve removal of the frenulum.

The procedure is voluntary and only offered to males able and willing to consent. This consent is achieved by providing a detailed explanation of the benefits, costs, and risks associated with male circumcision. The medical provider will emphasize what is guaranteed versus what is possible for the benefits, costs, and risks. With this knowledge, the individual may decide for himself if he wishes to proceed and be circumcised or not. The procedure is carried out only with his affirmative consent.

Circumcision is best carried out in a medical setting. It is recommended that, if the individual consents, this be performed in a sterile setting with trained professionals to minimize risks and negative outcomes. The risk of complications cannot be completely eliminated.

They can’t say that because it’s true and rules out the option to circumcise healthy children. Instead, they ramble about the perceived benefits. One should assign a level of trust corresponding to how forthcoming they are on the risks, so not much.

¹ WHO TECHNICAL ADVISORY GROUP ON INNOVATIONS IN MALE CIRCUMCISION: “Providers must be trained to recognize when an adolescent is not eligible for the PrePexTM device due to inability to retract the foreskin or discomfort while attempting to do so, or when there are adhesions or phimosis. …” The inability to retract the foreskin is normal at birth because it adheres to the rest of the penis.

² Even where it is something related to HIV, do we have enough to determine causation rather than correlation? Possibly. I don’t know. And to repeat, I don’t care if adults choose circumcision for themselves. What each person does with his body is up to him. Nor do I state unequivocally that all potential benefits are illegitimate. The argument for imposing circumcision on a healthy child in pursuit of those potential benefits is, though. Always. The removal of his foreskin is a price the individual may not wish to pay.

The Ministry Of Information and Communication Technology in partnership with the Ministry of Health and the centre for Disease Control in America are collaborating on a National Strategic framework known as the Voluntary Medical Male programme which is a joint government effort to eradicate the long struggle of HIV/AIDS infections.

HIV/AIDS has always been the countries top priority with the health ministry being pressured to reach their ambitious 2030 vision to bring HIV/AIDS infections to zero in the country.”The Centre for Disease Control and the Ministry of health have had three randomised controlled trial runs of the voluntary medical male circumcision programme prior to it’s launch in 2009. With the success of the programme around 20,000 sexual active males have been circumcised to date thus raising 80% awareness to men to encourage more males in considering medical circumcision,”said programme specialist Mr Dan Rutz of CDC.

Somehow success is measure in “males circumcised” without giving any statistics on HIV rates¹. So it’s easy to predict what “encouraging more males to consider ‘medical’² circumcision” means:

“Medical male circumcision has been found to be cost effective, as well as all procedures are free at clinics it has been known that healthy employers increases work productivity within any work environment which leads to a steady healthy work environment that enables the economy to grow,” added Rutz.All males that have not been circumcised are encouraged to do so as procedures can be performed at all local regional clinics in the country as government want to achieve it’s target to circumcise 330,000 men between 15 to 49 years by the end of 2016.The Ministry would also like to implement a national policy programme known as an Early Infant Circumcision strategy in the near future that will enable newly born babies to be circumcised.

“Enable”. Newborn males won’t get to consider or volunteer. They will be considered and volunteered, their needs, preferences, and preventative options deemed irrelevant. They are only pieces by which public health officials measure their own professional success.

As always, when public health officials discuss voluntary or adult circumcision, they never mean voluntary or adult.

¹ A drop in HIV infections would be welcome. It cannot justify violating ethical obligations to protect the rights of non-consenting individuals.

² Circumcision in this context is medicalized, not medical. Merely performing non-therapeutic genital cutting in a sterile operating environment does not make it necessary. This is also not a defensible term to justify performing non-therapeutic genital cutting on a person who does not offer explicit consent.

Join global health experts in PEPFAR’s sixth VMMC Webinar to consider the pros and cons of offering early infant male circumcision (EIMC) as part of routine Maternal, Newborn and Child Health (MNCH) care.

The title of the event was, “Scaling Up Routine Early Infant Male Circumcision within Maternal, Newborn and Child Health”. I wonder what the outcome of considering the pros and cons will be.

It’s also worth noting how circumcising infants has been separated as EIMC from “voluntary” male “medical” circumcision (VMMC). Is it progress if they’ve stopped pretending that infant circumcision is voluntary? Not really, I think, since no one involved cared anyway and dropping it means they’re comfortable with making it clear they don’t care.

I provided an answer to the doctor’s question, “If there was a vaccine for HIV that reduced the rate by 50%, would you be okay or would you be protesting?” In discussing the post with a friend, he offered an excellent follow-up to this. The doctor should answer this question: If there was a vaccine for HIV that reduced the rate by 50%, would you be okay or would you continue advocating for circumcision?

The doctor’s evidence-free accusation at the end, “anti-Semitic like you”, is both disgusting and interesting. I side with Brother K’s response and outrage on that charge. The problem is that no one in that video was talking to anyone else. Everyone was talking at each other. I assume all four people walked away thinking they won the interaction. Instead, I want the video where the doctor’s question gets a response rather than an information dump. Show him how his question – and by extension, his view of circumcision – is broken.

His question is excellent: “If there was a vaccine for HIV that reduced the rate by 50%, would you be okay or would you be protesting?” It provides insight into what concerns the doctor professionally. It provides a chance to discuss more about HIV than just this isolated 50% claim. It provides a direct way to distinguish the ethics of vaccination and removing body parts. It provides the doctor an opportunity to experience someone who has thought about this more than just “don’t hurt the babies”.

Non-therapeutic child circumcision is indefensible. The burden of proof should be on those who want to circumcise. They propose intervention. They haven’t proven their case. They can’t prove it because it’s flawed. But society puts the burden of proof on those who challenge tradition, not those who wish to intervene on the healthy body of a non-consenting child. It’s wrong, yes, but we have to work with society tilting at this windmill. Do we want to change society or do we merely want society to know we’re better? My preference is for the former, and especially so when seeing how little the doctor in the video agreed to the latter.

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It’s a valid expectation, so my answer to the doctor’s question is this:

Yes, I would be okay with it (qualified by verification of both efficacy and safety of the vaccine within some reasonable bounds). Circumcision isn’t a vaccine. Vaccine’s work with the body’s immune system to trigger a response that then protects the individual from infection. Circumcision removes skin. It operates on the theory of “less skin, fewer entryways”. This is relevant, too, since the mechanism for the claimed risk reduction from circumcision is unclear. Perhaps it’s a confounding factor not yet understood and/or researched? There’s also the scientific fact that condoms work better and do not involve the violation of human rights. And, what about the possibility that removing bits of female genitals could reduce risk? Are we ethically bound to allow that, too, or does it reveal the ethical question we don’t wish to consider? We know it’s unethical to investigate, because the answer doesn’t matter. Our societal fear is convenient, not justified, when it comes to HIV and circumcision.

I’ve written about the blog The Case Against Intactivism before. I don’t expect much when a rare new post comes through RSS from paper0airplane. There are valid criticisms to be made about the behavior of some activists. To that extent, I don’t mind paper0airplane approach. I avoid engaging in those behaviors because they’re flawed and unhelpful. And I’ve criticizedbadbehavior in the past. I have no concerns about my credibility on this, or the credibility of many others I interact with, so paper0airplane’s posts aren’t about me. That’s why their general focus is frustrating¹.

So it is again with the latest post, AIDS workers baby rapists, which highlights examples of idiots celebrating the deaths of prominent AIDS researchers on Malaysia Airlines Flight 17 because the researchers maybe had connections to circumcision. I don’t know what else to say about those intactivists beyond this: any individual engaging in this behavior is an untrustworthy ass and no ally of mine. Personally, I’m for individual rights. That includes the right to not have one’s genitals altered for non-therapeutic reasons without one’s consent. It also includes the right to not get blown out of the sky by murderers. Obviously. This isn’t complicated for most activists. But that doesn’t sell a canned argument.

It’s also clear how short-sighted these idiots are. I have no idea which portion of those who died were involved in research promoting circumcision for HIV risk reduction. All or none, it doesn’t matter. Their deaths are bad for the push for bodily integrity over circumcision without consent because some of the smartest minds searching for an end to HIV are now dead. Even if every one of them pushed circumcision, their absence means fewer knowledgeable people looking for a cure. I’d guess that means a push for circumcision is more likely, or at least likely to continue longer than if the researchers were still here working.

But, again, regardless, celebrating their deaths is ugly, garbage behavior. It’s wrong. I do not support it.

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The point I still take from paper0airplane’s overall approach is that the good intactivists should call themselves something else because the bad intactivists are ruining the term. Well, sure, if your gig is talking about any activists as if they’re all guilty of what the idiots among them do, you’d suggest this change. A flaw in that rests with paper0airplane. If I call myself an intactivist and don’t engage in awful behavior, why am I the one who should abandon² the label? The label is a decent, if goofy, expression of what this activism wants. I don’t call myself an intactivist precisely because it’s so easy for others to smear or to lazily blame me for the terrible tactics of others. But whatever I call myself, it isn’t my responsibility to relabel myself because paper0airplane criticizes too broadly.

¹ We can all play this silly, unfair game. But I’m not willing to suggest that everyone who supports non-therapeutic child circumcision must own Vernon Quaintance. That isn’t a reasonable demand.

² It’s reasonable to abandon it because enough people associate it with the actions of a few. The cause and effect issue there would be an interesting discussion.

Anyone familiar with the way voluntary, adult male circumcision is being promoted as a way to reduce the risk of female-to-male HIV transmission in high-risk populations already knows how it’s promoted. The brochure excludes context-specific qualifiers. That mouthful in the first sentence is always shortened to “circumcision reduces the risk of HIV”, even though that broad statement isn’t supported by the studies. In addition, voluntary, adult male circumcision loses words over time. Adult was the first word to go. Voluntary is still used, but that word doesn’t mean what it’s used to represent. Consent must only come from the patient when the circumcision is non-therapeutic. Absent that consent, the surgery shouldn’t be imposed on a healthy minor. In a discrediting move, no one adheres to that. It took six days from the 2006 release of the major HIV study on voluntary, adult circumcision in Africa for the U.N. to propose targeting infants first among all males in HIV-ravaged parts of Africa. Perpetuating circumcision via physical indoctrination is the new standard. Voluntary disappeared a long time ago as anything more than a marketing word.

I do not wish to suggest I think this is a conspiracy. Public health officials believe they are acting nobly. A well-meaning focus on one’s own preferences explains this at least as well. We must do something to reduce HIV. Circumcision is something. Therefore, we should circumcise. That’s bad logic, and relies too heavily on the nonsensical idea that someone happy with being circumcised proves everyone will be happy being circumcised. It treats the individual as a tool to achieve some public goal. That’s mistaken but it seems rooted in good intentions.

Now, knowing all of this, I’m difficult to surprise with how public health officials promote circumcision. I expect dumb, offensive strategies. I still can’t believe this from the opening of a new circumcision clinic at Tshepong Hospital in Klerksdorp, South Africa:

The clinic is called Gola Monna, or “Grow up Man” in Setswana. Its founder, Dr Limakatso Lebina, said: “This clinic will circumcise men and will ensure that they have lifelong partial protection against HIV.

“The removal of the foreskin clearly can’t stop all HIV infections but it certainly prevents most. [ed. note: dangerous misinformation] We tell all the men that we circumcise that they must continue to condomise,” she said.

Asked why women should be included, Dr Lebina explained: “Women should be involved in decisions about getting a safe circumcision. As mothers of boys and partners of men, they must ensure that the males in their lives are protected from HIV”

A quick pause to note how easily both adult and voluntary are missing as concepts in Dr. Lebina’s approach. This is more curious because MEC Dr. Magome Masike said that “communities must encourage men aged from 15 to 45 to come to this new clinic for circumcision.” A newborn male is not a man.

This, though, is absurd and offensive:

She added: “There is data to show women prefer circumcised men.[¹] So take a Valentine’s day decision to get a love cut and come in for male circumcision at the clinic.”

Rather than “voluntary” male circumcision, we have a “love cut”. This is no different than asking opponents “why do you want people to get HIV?,” as if one can’t be opposed to both non-voluntary forced circumcision and the transmission of HIV. Here, Dr. Lebina implies that an intact man who won’t have himself circumcised doesn’t love his partner as much as someone who would have himself circumcised. It’s preposterous. It also encourages parents to circumcise their sons because they love them. That’s twisted. Circumcision is not a gift.

Public policy needs to return to voluntary, adult male circumcision and mean it. Euphemisms like this, however well-intentioned, are Orwellian distortions that hide the ethical issues from those promoting and from those deciding on circumcision.

¹ The standard “women prefer circumcised men” is as expected here as it is irrelevant. Women (and men) are entitled to prefer whatever they want from a partner. They are not entitled to have it. What a partner prefers does not require a person to agree to have it done. Preference does not excuse imposing it on an individual in response to or as speculation about what a current or future partner prefers about his genitals.

In July I wrote about Zimbabwe’s plan to focus its “voluntary, adult” circumcision efforts on infants. This wasn’t a surprise because the truth always remains. When public health officials say voluntary or adult, they never mean voluntary or adult. And, as I wrote at the time in response to the claim that their “sole aim is to try and reduce new HIV infections”:

No, the sole aim is to implement circumcision. They believe their intentions are noble, a fact I do not doubt. But if their sole aim is to try to reduce new infections, they’d focus limited medical resources on those currently at risk of sexual transmission. They’re not, unless we stupidly assume all males aged 15 to 49 in Zimbabwe have been circumcised. Instead, they’re shifting to males who can’t consent. They still have 500,000 males to circumcise before 2015 to reach their target. The target is what matters, not the individuals being targeted.

There’s further evidence on both the low number of volunteers and the predictable efforts to “volunteer” infants. On the former (emphasis added):

Government intends to circumcise one million men between 2013 and 2015. The turnout has been very low in the previous years with only 85 000 circumcised since the inception of the programme. Chances of a man acquiring HIV from an infected partner if circumcised are less than 60 percent.

Instead of the 500,000 men who need to be circumcised, as reported in July, Zimbabwe is 915,000 men short of its goal. Or they intend to circumcise one million newborn “men”. Either way, it would be more prudent to ask why men (i.e. adult males) aren’t volunteering as expected than to violate healthy infants by forcing circumcision on them.

Also, notice the last sentence. In the best interpretation, it’s poor English. In the worst, it’s dangerously wrong. Regardless of the interpretation, men aren’t volunteering. Why? Instead of finding out, or publicly explaining why, public health officials push to impose non-therapeutic circumcision on children.

CHILDREN will soon be circumcised at birth under a national programme to achieve maximum results of the medical procedure, senior health officials have said. Aids and TB Unit director in the Ministry of Health and Child Welfare Dr Owen Mugurungi said Government was planning to start neonatal circumcision as soon as possible.

“We hope between 2013 and 2014 we would start neonatal circumcisions at a national scale,” he said. “It is actually more sustainable than adult circumcisions.”

Of course it’s more sustainable. Infants can’t refuse or fight back when they’re being violated. When public health officials say voluntary or adult, they never mean voluntary or adult. It’s easier.

[Dr Mugurungi] said for every 200 000 babies circumcised, about 1 500 new infections are averted.

Have they discussed the declining return, if their projections prove correct? (There is evidence to the contrary, as circumcised men in Zimbabwe may have a higher rate of HIV infection than intact men.) For every 1,500 fewer infections in their projections, the population-wide transmission rate decreases. Thus, the number of circumcisions needed to prevent each new infection increases. At what point in their flawed lack of ethics does the ethical question finally appear? When does the cost to individuals become too much to impose on them without their consent, allowing Zimbabwe to return to voluntary circumcision?

The answer, of course, is they haven’t and aren’t interested. The willingness to force circumcision on healthy infants is self-fulfilling. Ingrain it in the culture, and suddenly the rational respect for the current health and rights of infant males somehow appears absurd. The United States is evidence of this.